The Whimsy Of Serendipity

Years ago, a longtime patient of mine came to see me with an odd complaint: he’d developed spontaneous bruising on the top of his penis. “I honestly don’t know how this could have happened,” he said. “I certainly didn’t bang it on anything,” he added with a nervous chuckle.

He went on to tell me that the previous week he’d been on a bus when he’d been struck with a sudden pain in his left hip so excruciating they had to stop the bus and cart him off in an ambulance to a nearby emergency room. By the time he’d reached the emergency room, however, the pain had dropped to tolerable levels. The doctors there had examined him, x-rayed his hip (unremarkable, my patient reported), given him some pain relievers, and sent him home with instructions to follow up with an orthopedic surgeon and me. The bruising on his penis, he said, had developed only the day before.

I had him disrobe and examined him. The first thing I noticed was that he not only had a bruise on the dorsal aspect of his penis, he had one on his left thigh as well. When I had him lie down on the examination table, he seemed reluctant to lower his left leg, instead keeping it bent slightly at the knee. When I palpated his abdomen he displayed no tenderness, and I couldn’t feel any masses. When I moved his left hip, it proceeded through a full range of motion without causing him pain. That is, until I had him straighten his knee and lay his leg flat on the exam table, at which point he gasped in pain and quickly raised his knee back up.

“Where did that hurt?” I asked, puzzled.

“Right here.” He pointed to the lower quadrant of his abdomen on the left side.

“Sit up,” I told him. I pulled out my stethoscope to listen to his lungs. When I stood behind him to listen, however, I froze.

On the left side of his lower back sat a bruise about the size of my palm. I knew what I was looking at immediately. It’s called a Turner’s sign, named after the physician, Grey Turner, who first described it in 1920 in a patient with retroperitoneal bleeding from hemorrhagic pancreatitis. (The retroperitoneal space is a potential space that lies behind the intestines and houses the pancreas, the kidneys, ureters, bladder, the first part of the duodenum, and the two largest blood vessels in the body, the aorta and inferior vena cava.)

But pancreatitis seemed unlikely in my patient. He denied upper abdominal pain, nausea or vomiting, all symptoms you’d expect to see with pancreatitis. And given that the pain from pancreatitis is typically felt in the upper abdomen, why, I wondered, would laying his left leg flat cause him to experience pain in the lower abdomen? I didn’t know. One thing, however, was clear: he was bleeding internally somewhere. So I sent him down for an emergency abdominal/pelvic CT scan.

Thirty minutes later, a radiologist paged me. “Your patient has about a liter of blood in his retroperitoneal space,” he told me. That explained the Turner’s sign, as well as the bruising on his penis and thigh. Gravity had simply pulled the blood down from above through tissue planes to rest on dependent structures. But what had been its source?

“How does his pancreas look?” I asked.

“Fine. But he’s got a ruptured left iliac aneurysm.”

I was stunned. The iliac arteries are the two main arteries that branch off from the aorta in the mid-abdomen to supply blood to each of the legs. They’re major-sized and, like the aorta, are susceptible to enlargement (i.e., aneurysmal dilation). If they enlarge enough, their walls become weak and they can rupture. But also like the aorta, when they do, it’s a catastrophe: patients typically bleed out and die within minutes.

Based on the history my patient had given me, however, I thought the greatest likelihood was that his aneurysm had ruptured a full week ago, while he’d been riding the bus. How had he survived?

Apparently, the rupture had occurred in a tissue plane that brought it adjacent to his psoas muscle, the “marching muscle” that enables us to lift our leg directly skyward, like a soldier marching in formation. The psoas muscle sits directly on top of the iliac artery. Somehow, my patient’s psoas muscle had acted like a pressure bandage on his iliac artery’s rupture, significantly reducing the outflow of blood enough to prevent him from immediately bleeding to death. What should have been a geyser of blood had been transformed into a mere trickle.

A trickle slow enough for him to survive to not only make it to my clinic but to develop the one sign—skin bruising—that enabled me to make the correct diagnosis quickly enough to save his life.

I had a team of vascular surgeons rush to radiology, where they met my patient, looked at his scan, and took him immediately to the operating room. There they drained 1.5 liters of blood from his retroperitoneal space and repaired a large rupture in his left iliac artery.

In retrospect, his inability to straighten out his left leg without pain had been an important clue. In the medical literature a “psoas sign” is found on the right side: when extending the right leg, the psoas muscle is stretched tightly over an inflamed appendix and causes pain. In my patient’s case, however, his inability to straighten his left leg amounted to a left psoas sign, indicating not an inflamed appendix, but an inflamed arterial wall.

That my patient survived represents the most unlikely sequence of events I’ve ever witnessed in my entire medical career, a sequence of events that I found frankly chilling. For they reminded me of an uncomfortable fact that most of the time my colleagues and I pretend isn’t true: despite the vast body of knowledge and experience we’ve accumulated in medicine, sometimes the reason we succeed in identifying life-threatening diseases in time is because of one small, critical detail that we happen to catch purely as a matter of luck. Had my patient come to see me even one day earlier—without any bruising—I most likely would have missed the diagnosis, and he would have died.

Medicine, unfortunately, is full of stories like this. In the current era of technological wonder, our minds reject the notion that serendipity might be involved in medical outcomes, but the truth is that no matter how advanced our science becomes, serendipity—or karma, if you believe in its workings—will always play a role. I’ve seen nearly as many medical problems delayed or even missed as a result of a string of what appeared to be good decisions at the time that nonetheless happened to be wrong (and circumstances that happened to conceal that fact until later) as I have problems caught early and cured.

So though I celebrated my patient’s survival, the path he traveled to it disturbed me. We can do everything right with the information we’re given and still fail to find and fix problems that are findable and fixable. We are, all of us, to a certain degree at the mercy of forces beyond our conscious control.

This leaves with me with a sense of wonder and appreciation. Not only are you a wonderful diagnostician, but some times things just seem to happen. The answer to “what if?” is often “how come?” Good health to your patient and thank you for your posts.

Alex, I truly enjoyed reading your post. Thank you so much for sharing your experience. When you mentioned the L knee flexion, I was wondering what the psoas was up to. It is truly amazing to me this thing called life. I work with sick people all day long and I must say that I have come to believe that we are mere visitors and when we have done everything we are suppose to do, it’s our time to leave. I suppose it just wasn’t your patient’s time? I know my belief sounds silly, but it is what has helped me understand the unfairness of it all. Anyway…

Alex, this may not be the place to tell you this, but I wanted to let you know that I have been troubled for a while now about one of your posts, maybe even longer than a year or close to it, anyway. You wrote about karma, mentioned that the child being abused might just have been Hitler in his past life, and that the abuse would seem right then. Maybe I misunderstood you? Or, maybe I have been thinking about it for so long, I just can’t remember exactly what you said concerning this, and my silly little mind just ran away with it? I do know that it has troubled me for awhile now. I keep asking myself if whoever or whatever I was in my past life, if I have a past life, even begins to explain the abuse from my earlier years? And if it does explain it, does it make it right? Please forgive me if this isn’t the right time or place.

Brendalee: Whenever I discuss the concept of karma, the single issue with which people struggle the most is the one you mention: how can an innocent baby be responsible for being born to abusive parents? Most minds rebel against the idea. But if life truly is eternal—if we are reincarnated—and the principle of cause and effect is true, then it’s merely something that follows logically. If you go back to the original post, however, you’ll note the important distinction between “blame” and “responsibility.”

The problem with the notions of karma and cause and effect, however, is that while they attempts to explain how, for example, a baby can be in some sense “responsible” for being abused (i.e., have inadvertently called abuse into his or her life), it strikes me as a non-provable hypothesis. It may deliver an important sense of ownership for our fate to us and imbue us with a sense of hope that any karma, any set of circumstances, is changeable, but right now the only way I see to become convinced the law of cause and effect actually operates is via a great awakening, i.e., enlightenment. While I obviously remain hopeful for this (as I still practice Buddhism), the scientist in me remains extremely skeptical.

Fascinating, and chilling! Thank G-d you facilitated his survival, but as you say, his life was delivered on a gossamer thread. Oh that more physicians possessed your sense of awe; perhaps they would be less likely to prescribe by the numbers.

This is a very humbling story, and serendipity is the gist of it … his, yours, and everyone’s. Thank you for sharing.

Hello from Tallinn, Estonia. Your patient was lucky, and you took the time and care to realize that Murphy was at work. Nice job. There is the old army saying that “if you cannot take a joke, why did you join?”—My mother, who was a strong Irish-Catholic, used to say that God has a warped sense of humour. As Hitch puts it, the answer to to “Why me? ” is “Why not?” I also enjoy your posts.

I must say, I myself have witnessed/in cognizance of such circumstances in real life (although I am not a doctor myself). One of it, narrated by one of my Engineering lecturers was as unnerving as your story above. The story goes as follows: My lecturer and some of his friends were waiting at a bus stop to catch the bus to his hometown. These buses had very low frequency and thus was always crowded; however, my lecturer and his friends were ready to push their way through the crowd and secure seats for themselves. A few minutes later, the bus arrived and as expected was crowded inside. Amidst the frenzy of travelers getting into and out of bus, my lecturer and his friends were not able to make it inside, while one person from behind pulled out my lecturer so that he fell on the ground and made his way inside. As is usual in India, buses don’t wait for passengers to be boarded. It left, leaving behind the grumbling bunch of people and my lecturer cursing that unruly person, who had shoved him to ground.

However, just as he was getting up from the ground, with the help of his friends and tending his bruises, he heard a loud noise of collision. A speeding truck from across the street had banged into the same bus from behind at the next square. It was a deadly collision. The bus had been crushed badly from behind and deaths had been immediate. People began gathering around the accident site, taking out people from bus, who had not been crushed to death. The truck driver, though badly hurt, was still alive. My lecturer and friends too rushed to the site to witness the destruction and lend helping hand to the beleaguered passengers.

However, as he was lending out a helping hand to people, he saw the corpse of the same guy who had pushed him down to ground at the bus stop, his head and legs crushed. This sent a chill down his spine as he thought how close he himself had been to that same death. The death that had been swapped by that bully.

As he narrated the story, he shivered from the memory of it, and so did I, thinking, so close are we to “not-being” at all times, yet so engrossed in our attempt at “being” eternal. This story has stuck with me somehow, and at all times, it humbles me.

I’m not a doctor, but I knew the diagnosis immediately when I read that the retroperitoneal space contains “the two largest blood vessels in the body, the aorta and inferior vena cava”—because this is EXACTLY how my father died!

Dad was a very active man all his life, and very tough in terms of enduring discomfort or pain without complaint. He’d felt a little unwell during the week before his death, but had dismissed it because out-of-town relatives were visiting. He insisted on accompanying them on their sightseeing (lots of walking & standing) over the course of several days.

The beginning of the next week, however, he was suddenly struck with such intense pain in his hip that he agreed to go immediately to the family GP (whom he generally avoided on the grounds that he wasn’t ever sick!). In attempting to be “taken seriously” by the doctor, dad claimed to have had chest pains (even though he hadn’t). The GP sent him straight to cardiac ICU, where dad dropped dead, literally in mid-sentence, several hours later.

His death certificate says he suffered cardiac arrest (no autopsy was done). But in the years since then, every cardiologist to whom I’ve described the sequence of events—and in particular, the severe hip pain (which occurred about 9 hours before he died)—has said “ruptured inguinal aneurysm.” It appears that none of the docs at the hospital where he died ever considered that diagnosis, apparently thrown off by dad’s false claim of chest pains.

A month before his death, I overheard him remark to another relative “I hope when I go, I go fast & in a way that I can’t be revived from, and that I never know what hit me.” He had great intuition, which was often derided during his life by others. Did he “know” what was ahead, or that something was on the horizon? I can only say that, by dint of his own personality quirks, he got his wish!

Thinking about this unusual type of bruising—does it hurt like regular bruises? Were his feet also bruised? If not, why not?

et: No feet bruising because not enough time had passed to allow the blood to seep down that far. It didn’t hurt where he was bruised because he hadn’t been struck there (most bruises hurt because the bruising occurs at the site of injury/impact, unlike in this case).

Serendipitous? Or perhaps the lesson is: Everything is in perfect order, even if things are contrary to our best-laid plans.

Likewise, from last week’s post, probably everything was in perfect order for that patient who had his vision salvaged but died of “complications.” The fact that we may not know just how that situation played out/ended well is beside the point. We don’t need to know.

I know a true skeptic cannot take many leaps of faith, and won’t admit that there are things we cannot know/prove. Nor will such a skeptic admit that we don’t need to know (all the reasons and outcomes).

But I believe this is so. I have been humbled by the nagging feeling that there must be a bigger picture/plan way too often. So now I am a believer.

I find the medical problem interesting and have had serendipitous things happen in vet med. Probably not so close to being fatal but a lucky diagnosis. But on karma and the baby. It may be Hitler reincarnated but the baby did not learn anything from the trauma inflicted on it. So it didn’t deserve it or earn it. Of course, I didn’t read the original article so the thought may be off base.

More than serendipity, I feel the patient owes a lot for his survival on you concern and compassion towards your patients. I mean this since I have seen doctors who despite narration of tell-tale symptoms pay little attention to the lamentations of the patients.

A very interesting and thought-provoking story. It reinforces my belief there’s no such thing as “coincidence.” That there is a season and purpose for everything and everyone. Although your patient’s life could have ended on the bus that day, he survived in spite of a normally fatal ruptured aneurysm. Today he lives to reflect (hopefully) on his life saved and to be thankful either to you, or if he believes, a greater Being. And you get to tell of a medical event that maybe has you and some of us reflecting momentarily or longer, on our lives, our part in fate and the mystery of our existence.

Alex, it sounds like your patient was aware of the pain caused by straightening his knee, but didn’t tell you, or other doctors, about it. If this is the case, it seems like this is not just a case of serendipity, but also one that reminds that we often don’t say everything to our physician, endangering our lives.

This is a perfect example of being in the right place at the right time. Moreover, it seems to me that for whatever reason all events led to one main event. Fortunately for your patient it was his appointment with you, whereby you were able to immediately diagnose him, which consequently save his life.

Life is a mystery. Lessons to be learned from the perspective of both the doctor and patient to be sure.

Very interesting post, Alex. Having read a number of your posts, there’s a blog I think you might enjoy, and this serendipitous story makes me think of a particular post: The Texas Sharpshooter Fallacy. (Perhaps you’ve already seen David McRaney’s blog.)

I link to that post not because I think you are demonstrating the Sharpshooter Fallacy here (quite the reverse), but simply because I think it’s salient to the questions of meaning and randomness that are raised in your remarks and in the comment thread. McRaney’s post paints things as rather black and white, which I tend to find they are not, but over all it’s very enjoyable.

Sometimes I think it’s amazing that, with all the complexity of the human organism, and all that can go wrong, so much goes right.